Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Thursday, December 26, 2013

American Exceptionalism

I hope everyone is enjoying their holidays, to whatever extent you have them. I'm actually at work today but I'm all by myself. Just some things I needed to get done. Anyway . . .

Like a whole lot of nonplussed observers, I find the American habit -- nay, the ironclad requirement of acceptable public discourse -- of insisting that the United States is uniquely great, the best at everything, and exempt from the moral standards that apply to other nations not only epistemologically warped, but factually preposterous. Even our exceptional wealth, derived first from the exploitation of a sparsely populated by well-resourced continent, then enhanced by our triumph in World War II and post-war hegemony, is well on the way to depletion.

But that's the least of it. Even at the height of our national wealth and power, our welfare as a people was exceptional only for our failures. Throughout the post-war era, despite our greater total wealth, we have had less equality, more want, and worse health than western Europeans, and now even more countries are catching up to us and exceeding us in measures of social welfare. The military empire is financially unsustainable and brings us no evident benefit, yet we seem determined to squander everything it takes to maintain it. Our physical infrastructure is rotting before our eyes and out leadership in scientific and technological innovation eroding. As everyone knows, the material standard of living of most of the population has been declining for two decades, as whatever increased wealth we generate is hoovered up by the very wealthy. And yet our political discourse is dominated by an axiomatic belief that the greatest threat to our future is the possibility that we will spend the resources needed to fix these problems.

The issue of health care costs is one I think about professionally, so I'll present it as an exemplar of our broader malaise. Spending half again to twice as much as comparable nations on health care gets us worse health, which is I suppose the major theme of this blog. But why does this happen?

Inequitable access. For all we spend on people lucky enough to have health care coverage, there is a good 15 to 30% of the population, depending on who you count and what you consider inadequate, that can't obtain the full benefit because they can't pay for it. That doesn't happen anywhere else among the wealthy countries. It's one thing about us that is exceptional.

Overpayment. All the other countries have, one way or another, bargaining power with the suppliers of medical goods and services that keeps prices low. Note that this does not, as free market fundamentalists claim contrary to all evidence, result in inadequate supply or lower quality. Because of the way medical markets work, which I won't go into right now but will be happy to discuss (yet again) on request, an unregulated market results in overpriced inputs. We also have powerful vested interests, such as certain medical specialties, that essentially extract rents.

Overuse. About 1/3 of medical intervention is unnecessary, useless or harmful. Again, that doesn't happen in countries with rational health care systems.

And, taking a step back in the causal chain, why are we so dysfunctional? It's because of our political culture which enables rentiers and thieves to win in the legislature. They have much of the public bamboozled into thinking that solving national problems and producing some modicum of justice will, by some unexplained mechanism, make people not be "free"; and that it will mean stealing from them to benefit the unworthy. Racism has a lot to do with this, and so does our frontier history and our puritan heritage and a whole lot else I'm sure.

But if the medical-industrial complex continues to rob the public as it is doing, and medical costs grow in the future as many fear they will, national and local government will find it increasingly difficult to pay for education, physical infrastructure, sustainable energy and other critical investments, and social welfare. Our economy will be hollowed out, and our future bleak. Yes, it would be good to stop squandering money on useless military hardware and soldiers with nothing good to do, but that is actually a much smaller problem on a purely cost basis.

What is to be done? Many say the Republicans have become too extreme to be credible, yet they continue to win elections. The consensus prediction is that they keep the House and maybe even grab the Senate next November. There is no penalty for lying to the public, the corporate media just transmit it, and even amplify it by running with whatever conventional narrative the liars manage to establish. Oceans of unaccountable, anonymous money will continue to drown the electorate.

What is to be done? I have always believed we need to organize. Old models of organization, through labor unions and traditional issue based and identity politics, aren't working well any more. We need to innovate. I will continue to think about this, I hope you will too.

Preach.I will never understand why the average American thinks it is "okay" to go bankrupt from healthcare. I find it appalling that we bicker over universal coverage worried about some evil -"ism" being attached to the idea. Don't these fools realize how wonderful it would be to be able to take any job you want without having to worry if there is healthcare coverage?

I do not think, Cervantes, that selfishness per se is at the root of it with the majority of republican voters. They are no better off, and often worse off, than the people they detest. It has been said repeatedly and correctly that they vote against their own self interest. Why?

http://youtu.be/RoMTfjgC6GM

Because humans are not rational actors, or rather, we have keenly developed survival instincts for a completely different environment. In this case the ongoing impoverishment of 90% of the population has made them cling harder to their tribe, which would have been the right answer until quite recently (i.e. 100 years ago in the west).